Wisconsin Diabetes Leadership Initiative Demonstration Project

Submission Date: December 2013

Entry Type: Case Study

State/Territory Submitted on the Behalf of: Wisconsin

States/Territories Involved: Wisconsin

Domain Addressed:

Health Systems Strategies

Public Health Issue:

The prevalence of diagnosed diabetes in Wisconsin adults increased from 5.3% to 7.1% between 1999 and 2010. Diabetes is a public health priority since much of the illness it causes is preventable. Early detection and management of major diabetes complications, including cardiovascular and kidney disease, can slow their progression and improve quality of life for people with diabetes.

Project Objectives:

• To create and provide educational tools for consumers that will increase awareness of 2 major complications of diabetes – diabetic kidney disease and high blood pressure.
• To create and provide educational tools for health care providers that help them increase patient engagement and understanding of test results
• To give providers additional strategies for improving care of people with diabetic kidney disease (DKD) as well as patients at risk for cardiovascular disease due to diabetes.

Program Action:

The Wisconsin Division of Public Health (WI-DPH) collaborated with a practice-based research network partner in 3 network clinics in the Madison area. The partner was conducting a research project in multiple, ambulatory-care clinics in Wisconsin to address chronic kidney disease (CKD). The DLI project offered an educational intervention missing from the network’s existing efforts and provided an opportunity for WI-DPH to complement the network’s activities by giving providers additional strategies to improve care of people with DKD as well as patients at risk for cardiovascular disease due to diabetes. WI-DPH created educational tools based on health care provider feedback as they worked to improve the communication of lab test results and physician recommendations for select patient self-management strategies. The tools were designed to increase consumer awareness and understanding of two specific diabetes complications – DKD and high blood pressure. Healthcare providers and others at clinic sites were offered additional educational resources to increase patient engagement and understanding of test results.

Funding was provided to NCDPH through the Diabetes Leadership Initiative spearheaded by NACDD with support from the Boehringer Ingelheim and Eli Lilly Company alliance, as well as to additional demonstration project states. Wisconsin’s project was unique compared to the other states in that its primary partner was a data intermediary rather than a health care delivery site and WI-DPH had a more limited role in oversight of project implementation. Prior to the DLI, the partner had involved the three DLI-participating clinics in a project related to improving care for CKD. Most of the measures tracked as part of this project were also tracked for the previous project and health system changes related to kidney disease, such as changes to the EHR, had been implemented in 2011 before the DLI project was underway.

Data/Other Information Collected:

The network received funding to support data collection; data was supplied to WI-DPH as aggregated baseline data and quarterly data. Each data submission included number of partners, providers and patients reached by the project, and these measures for people with diabetes, based on ADA Standards of Medical Care in Diabetes-2012 which were in place at the time the project began:

• A1c <8%*
• BP <130/80 mm Hg
• LDL<100mgdL
• Non-smoker
• Annual test for urine albumin excretion (UACR)
• Annual estimated glomerular filtration rate (eGFR)
• ACEI/ARB prescription for nephropathy
• Medical Nutrition Therapy (MNT) referral as needed
• Renal specialist referral when eGFR<30; uncertain etiology or difficult management of kidney disease

[* ADA standards state “Less-stringent A1C goals (such as <8%) may be appropriate for patients with a history of…advanced microvascular or macrovascular complications”]

The evaluation methodology used a rolling annual data analysis time frame – each quarterly submission of clinic data included the previous 12 months of aggregated data. The data on care management were gathered primarily to give partner clinics a tool for monitoring changes resulting from project efforts and represent a point-in-time. Factors affecting interpretation of the data included an ongoing project which collected similar kidney disease measures and statistical phenomenon such as seasonal variation and regression toward the mean.

Impact/Accomplishments:

• The project had worked with 6 health care providers and reached over 400 people living with diabetes by Q7 of the project.
• Clinics reported implementation of the following health systems changes: (see complete list in the WI project summary at: (To be posted when available)  — Providers use the kidney health tool developed by WI-DPH (with local health care provider feedback) to help them explain lab results, to reinforce patient self-management strategies to lower risk and preserve kidney function, and to support and address the reporting of kidney test results.– Clinics reorganized their patient flow to accommodate patient viewing of a WI-DPH-developed educational DVD titled The Links to Chronic Kidney Disease: Diabetes, High Blood Pressure, and Family History and also offered a copy for home viewing and sharing with family.

  — Clinic nurses now use patient contacts, such as a call for prescription refills, to identify patients needing kidney or other diabetes-related testing which they then discuss with primary care providers who can order the necessary tests.

The relatively stable clinical outcomes between baseline and Q7 for all project measures may be a reflection of the progress made as a part of previous work related to improving care for CKD. Among the patients with diabetes, clinics  reported that kidney disease screening measures showed no significant changes between baseline and Q7 but were already high at baseline at 100% for eGFR and 95% for the UACR/Both UACR and eGFR measures. Among the patients with diabetes and stage 3 or 4 DKD, clinics reported that the percentages of stage 3 or 4 DKD patients who achieved the recommended clinical management goals and the additional measures related to kidney disease management remained mostly unchanged between baseline and Q7.

Challenges/Lessons Learned:

Challenges/Lessons Learned

When expanding the initial work to other clinic sites, NYSDOH used several criteria to identify higher priority sites and readiness: 1)no recent clinic leadership changes, 2) well-established internal champion and/or physician, perhaps already working on quality improvement but not currently overloaded with ongoing QI programs, 3)well-organized and managed site.

Key learnings states, partners and NACDD took from the initiative which will apply to future health systems change projects include:

• Establishing a functional team is very important to health systems change – physicians, nurses, registered dietitians, patient care coordinators, community health workers, leadership staff, IT staff and vendors – all must be involved in planning and executing health systems changes for the most efficient and effective result.
• Public health should enter systems-change partnerships with an eye to sustaining and extending expected successes and health system improvements. This means an upfront assessment of partner’s readiness and potential for sustaining and extending changes.
• Every level in a clinic setting is essential to implementing systems changes. All clinic staff needs to know how their work relates to quality improvement and how it supports patient management.
• Relate health systems change project to meaningful use, use data to correct system design and collect data with the intent to improve the system. Most DLI project measures partners reported are aligned with meaningful use measures.
• Align health systems quality improvement projects with reporting requirements to increase motivation of providers to participate.
• Data collection is vital since ongoing review of the data can drive system improvements.

Program Areas:

Diabetes

State Contact Information:

WI
Mary Pesik, RD, CD, Chronic Disease Prevention Unit Supervisor (Mary.Pesik@wisconsin.gov), Pam Geis, Health Promotion Specialist (Geis.Pamela@gmail.com)
State of Wisconsin Division of Public Health
608-267-3694 (Pesik), 262-573-3983 (Geis)
Mary.Pesik@wisconsin.gov

<< Back to All Success Stories